pain

A high-quality study from the Monash Cabrini Department of Musculoskeletal Health and Clinical Epidemiology has provided valuable insights into both patient and healthcare professional barriers and enablers to deprescribing opioids.

These findings will aid in the development of tailored, evidencebased deprescribing strategies for reducing overuse of opioids for chronic non-cancer pain.

Chronic non-cancer pain is pain that persists beyond three months unrelated to malignancy. It is highly prevalent worldwide. Despite evidence indicating limited, if any, benefit and substantial risk of harm of opioid analgesics in the management of chronic non-cancer pain, opioid use is extremely common.

High-risk prescribing is a major problem. In Australia, almost three million adults use opioids for chronic non-cancer pain each year. Dispensing increased 15-fold between 1992 and 2012. To take a significant step forward in tackling this global problem, we need research about why this occurs to inform safe and effective interventions for deprescribing opioids for chronic non-cancer pain.

We now have new evidence from a study led by Dr Amanda Cross and Associate Professor Denise O’Connor (pictured) from the Monash Cabrini Department of Musculoskeletal Health and Clinical Epidemiology. Their study involved an extensive analysis of the existing literature on patient and healthcare professional reported barriers and enablers to monitoring and deprescribing opioids for chronic non-cancer pain.

They identified five key barriers:

• that there are limited alternatives to opioids

• management of pain is considered the top priority

• patient understanding, expectations and experiences of deprescribing are limited

• there are strong pressures to prescribe opioids

• and a reluctance to change is common

‘environmental context and resources’ (for example, perceived or actual lack of alternative analgesics) and ‘social influences’ (for example, the need for supportive patient-provider relationships). Strategies that could address these factors included providing better access to chronic pain clinics and non-opioid alternatives, providing healthcare professionals with evidence-based guidance, tools and training to support deprescribing, and restricting quantities of opioids.

Joint replacement surgery is the treatment of choice for patients with advanced joint disease, and is most commonly performed for severe hip or knee osteoarthritis.

With growing surgery rates around the world, we need to ensure the continually rising cost of performing high numbers of these procedures is truly valuable in terms of improved health outcomes. Understanding the patient’s perspective on the outcomes that matter to them is a critical part of this decision making.

Patient-reported outcome measures (PROMs) are commonly used to evaluate surgical outcomes from the patient’s point of view and can provide valuable information regarding pain, function and quality of life after surgery. The information can be incredibly valuable for monitoring patient outcomes, supporting quality improvement activities and enabling benchmarking

However, PROMs are only useful tools if meaningful data are collected in a valid and reliable way. With different types of PROMs available, organisations need to consider ease of use of the PROMs instrument, the burden it places on the patient to respond and the key measurement properties of the PROMs instrument to ensure useful information is collected that can support clinical care.

A novel study led by Professor Ilana Ackerman from the Monash Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, published in Osteoarthritis and Cartilage journal, has tested two new PROMs for the first time with real-world longitudinal data. The Hip disability and Osteoarthritis Outcome Score (HOOS-12) and the Knee injury and Osteoarthritis Outcome Score (KOOS-12) PROMs, together with other diseasespecific and generic (non-disease-specific) PROMs instruments, were piloted over a two year period by the national Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) pilot PROMs program. The study provides the first evidence of their reliability and validity to evaluate patient outcomes after joint replacement.

110,000+ hip and knee replacements are performed in Australia annually

Prof Ackerman’s study included an extensive analysis of HOOS-12 data from 3023 patients undergoing primary total hip replacement and KOOS-12 data from 4010 patients undergoing primary total knee replacement.

She explains “The HOOS-12 and KOOS-12 PROMs were more responsive to change than other commonly used measures (for example, the Oxford Hip and Knee Scores and the EQ5D-5L). The HOOS-12 and KOOS-12 also offer the advantage of generating separate pain, function and quality of life subscale scores—all important indicators of patient outcomes after hip and knee replacement surgery. The shortened format of these instruments (12 items vs 42 items for the original HOOS and KOOS tools) also reduces the responder burden for patients.”

The study has demonstrated that the new HOOS-12 and KOOS-12 PROMs instruments are reliable, valid and responsive measures for evaluating outcomes after joint replacement surgery for osteoarthritis. Their ability to track improvement in hip and knee-related pain, function and quality of life after joint replacement surgery will be extremely valuable to patients, clinicians and registries.